Barriers and Facilitators to the Use of Delirium Screening in Medical-Surgical Settings: A Mixed Methods Pre-implementation Study

Abstract

Purpose: Pre-implementation research is needed to determine which factors to address before beginning implementation of delirium screening in acute care facilities. This study aimed to understand factors influencing medical-surgical nurses’ use of delirium screening tools, and to identify activities that would address barriers and build on facilitators of implementation.

Background: Delirium remains a significant complication for older adults hospitalized in the medical-surgical setting. Thirty-two to sixty-six percent of delirium remains unrecognized, resulting in inadequate delirium management for older adults. Previous studies have identified that intent to implement an innovation is influenced by knowledge, attitude, values, and beliefs.

Methods: This pre-implementation study utilized an integrated mixed-methods explanatory sequential design. In phase I, medical-surgical nurses completed surveys to elucidate factors that may encourage or inhibit delirium screening. Surveys included the Nurses’ Knowledge of Delirium Questionnaire (NKD), the Evidence-Based Practice Attitude Scale-36^© (EBPAS-36^©), and the Delirium Screening Appraisal (DSA). In phase II, a subset of RNs were interviewed to explore perceptions of the barriers and facilitators to the implementation of delirium screening in the medical-surgical setting.

Results: In phase I, ninety-two medical-surgical RNs scored a mean of 66% total correct on the NKD with the lowest scores related to identifying risk factors of delirium. RNs scored a mean of 2.83 on the EBPAS-36^© indicating a moderately positive attitude towards evidence-based practice. Eighty-three percent of the RNs indicated an intent to change practice. Twenty-five RNs were interviewed for phase II. Eight themes were identified; four barriers to implementing delirium screening tools (DSTs) (Don’t change my Routine, Overwhelmed by tasks, Leadership Doesn’t understand, and Inconsistent Staffing) and four facilitators to aid implementation (Using the Delirium Screening Tool Improves Delirium Identification, Identification Improves Patient Care, Has to be in the Electronic Medical Record, and Education is a Must).

Discussion/Conclusion: As found in previous studies, nurses’ knowledge of delirium remains less than optimal, especially knowledge of delirium risk factors. This study supports the use of pre-implementation assessment to identify potential barriers and facilitators that could influence the implementation of delirium screens on the medical-surgical units. This information is critical when selecting strategies to aid implementation.